Vital Signs Signs of Life

Vital Signs (VS) Learning Objectives: Overview of Vital Signs 5 main VS Definition of Pulse How to obtain & accurately measure each pulse Identify sites for assessing pulse Practice accurate measuring of pulse and recording results Medical Terminology

Vital Signs Assignments: Discussion Articles Reading Textbook Note taking Handouts Pulse Points Graphic Chart Review

Vital Signs (VS) Discussion Vital = Life Why do we need to know information about and how to take vital signs (VS)? Why is it important to obtain all patient’s VS? How often should we take a patient’s VS? What can VS tell us about our patients? Is it important to know what a patient’s normal set of VS is? Why? What do we do when VS are abnormal or out of normal range?

Vital Signs Defintion: Important information about the condition of a patient’s body Detect Changes in normal body function May signal life-threatening condition Provide responses to treatment Usually taken at rest with person sitting or lying down

Types of Vitals Five Main Vital Signs: Documented as: Temperature (T) Pulse(P) = heart rate Respirations(R) Blood Pressure(BP) Pain Score Documented as: TPR, BP and Pain Score

Vitals are Measured Upon admission As often as required by the person’s condition Before and after surgery After a fall or accident When given a drug that can affect a person’s respiratory or circulatory system When patient complains of pain, dizziness, shortness of breath (SOB) or chest pain

Vital Facts about Assessing Vitals Any extreme variations must be reported immediately Extreme abnormal high or low rates must be reported immediately If unable to obtain report immediately Certain factors will change readings of vitals especially pulse, respirations and BP. Increased rate can be affected by Exercise Stimulant drugs Excitement Fever Shock Anxiety

Decreased rates can be affected by: Sleep Depressant drugs Heart Disease Coma Physical Training

Pulse

Pulse (P) Definition: pressure of the blood felt against the wall of an artery as the heart beats Pulse Characteristics: Rate = # of beats per minute Rhythm = regularity / irregularity Volume - = strength – described as strong, weak or bounding

Pulse (P) Obtained: by palpation (to feel) of an artery and count the number of beats. If regular can count 15 sec. X 4 or 30 sec. X2. If irregular count full 60 seconds or auscultation (to hear) of an artery Normal: -rate = varies by age, sex and body size - rhythm = regular - volume = strong, not bounding

Measuring Radial Pulse Procedure 1. Assemble equipment 2. Wash Hands 3. Introduce self 4. Place patient in comfortable position with arm supported 5. With tips of first two or three fingers (prefer middle finger and ring finger) , locate the pulse on the thumb side of patient’s wrist. Never use thumb. WHY?? 6.When pulse is felt, exert slight pressure and start counting. Use the second hand of watch and count for full minute or 30 seconds X 2 or 15 sec. X 4 unless irregular then must count for full minute. 7. When counting pulse, note the volume (character or strength) and the rhythm (regular or irregular) . NOTE MAKE SURE ALL PULSES ARE BILATERAL and SYMETRICAL… 8.Record the following information: date, time, rate, rhythm and volume using agency policy for recording

9. Check the patient before leaving 9. Check the patient before leaving. Observe all safety precautions to protect the patient 10. Replace all equipment used. 11. Wash hands 12. Record all required information on the patient’s chart for example. 8/22/16 0900 P82 strong and regular R. Davenport, RN

Bradycardia – less than 60 bpm Tachycardia – greater than 100bpm Pulse (P) Terminology Bradycardia – less than 60 bpm Tachycardia – greater than 100bpm Arrythmia – irregular heart beat -

Pulse Points Temporal – side of the forehead Carotid – neck (used during child/adult CPR) Brachial – inner aspects of forearm at the antecubital (crease of the elbow). Used for BP and infant CPR Apical – below left breast. Most accurate pulse point. Use stethoscope and count for a full minute. Radial – at the inner aspects of the wrist, above the thumb (thumb-side). Most common site to assess pulse. Femoral – at the groin (inner side) Used for assessment and procedures Popliteal – behind the knee. Used for assessment Dorsalis pedis – top of the foot arch (between Big Toe and 2nd toe)

Pulse Normal Ranges Age Infant Child 1-7 years old Child 7-12 12 years and older Pulse Per Minute 100-160 80-110 90 60-90

Charting Vital Signs See graphing handout

Temperature

Temperature (T) Definition: the measurement of the balance between heat loss and heat produced by the body Obtained: Oral – mouth – 98.6 (Most common) 3-5 min. Wait 15 minutes after eat, drink or smoke. Rectal and/or temporal – - 99.6 (most accurate)3-5 min. Used on infants and small children tympanic/aural – 98.6 (less than 2-5 seconds) axillary – armpit or groin - 97.6 (10 minutes)

Temperature (T) Measured: Degrees Fahrenheit / Celsius Normal Body Temp – 98.6 F / 37 Temp affected by: Body processes- some people have accelerated body processes which produce a higher body temp Time of day – Body temp is lower in morning after body has rested and higher after muscular activity and daily food intake

Body Sites: The various sites of taking temp will affect the reading. Causes of increased body temp: illness, infection, exercise, excitement and incr. environment temperature Causes of Decreased body temp: Starvation or fasting, sleep, decreased muscle activity, mouth breathing.

Hypothermia- body temp below 95F ® Hypothermia- body temp below 95F ®. Death occurs if body temp drops below 93F for a period of time. Hyperthermia – temp exceeds 104F ®. Caused by prolonged exposure to high temp, brain damage and serious infections. Temp above 106F can lead to convulsions, brain damage and death.

Inhale & Exhale Respirations

Respirations(R) Definition: reflection of breathing rate of patient . Process of taking in O2 and release CO2 Obtained: look, listen, feel Measured by : Rate = # of breaths per minute Rhythm = regular / irregular Character = labored, non-labored, shallow,

Respiratory Terminology Dyspnea- difficult or labored breathing Apnea- absence of respirations Tachypnea- fast, shallow resp. above 25bpm Bradypnea- slow resp rate below 10bpm Orthopnea- severe dyspnea when laying down Cheyne-Stokes- period of dyspnea and apnea Rales- bubbling noises caused by fluid Wheezing- high pitched whistling (expiration) Cyanosis- condition of bluish discoloration

Blood Pressure

Blood Pressure (BP) Definition: the force exerted by the blood against arterial walls when the heart contracts or relaxes Obtained: Sphygmomanometer & stethoscope Dynamap (automatic, no stethoscope) Measured: Systolic – ventricle is contracting Diastolic – ventricle @ rest

Blood Pressure (BP) Normal Range: varies by age Hypertension: Definition – High blood pressure; Systolic > 140 and/or Diastolic >90 Causes- Stress, anxiety, obesity, Incr. sodium, aging, kidney disease, decr thyroid function and vascular conditions

Hypotension: Definition – Low blood pressure; Systolic < 90 and/or Diastolic < 60 Causes- Heart failure, dehydration, depression, burns, hemorrhage and shock Orthostatic hypotension – Occurs when a drop in either systolic or diastolic when moving from lying to sitting or standing position. (inability of blood vessels to compensate quickly)

-algia Pain

Pain 5th VS Is a subjective symptom Measured: By severity on a scale of 0 – 10 According to location By description – sharp, stabbing, dull, etc. By occurrence: constant vs. intermittent Obtained: From patient via verbal or non-verbal communication

Review Abbreviations: VS BP R TPR Sx F C bpm

Review Name the 5 VS 2. What is the most common site for taking a pulse? 3. What is the heart rate less than 60 bpm called? 4. Give one reason that an apical pulse should be taken. 5.What is an irregular heart rate called? 6. Why is it important to obtain a person’s VS? 7. Give three instances when vitals should be obtained.